Pichapong Tunsupon

Right Ventricular Echocardiographic Parameters Are Associated with Mortality after Acute Pulmonary Embolism

BACKGROUNDnThere is limited information on the utility of certain echocardiographic measurements, such as right ventricular (RV) strain analysis, in predicting mortality in patients with acute pulmonary embolism (PE).nnnMETHODSnA total of 211 patients with acute PE admitted to a medical intensive care unit (ICU) were retrospectively identified. Echocardiographic variables were prospectively measured in this cohort. The focus was on ICU, hospital, and long-term mortality.nnnRESULTSnThe mean age was 61 ± 15 years. Median Acute Physiology and Chronic Health Evaluation IV and simplified Pulmonary Embolism Severity Index scores were 60 (interquartile range, 40-71) and 2 (interquartile range, 1-2), respectively. Thirty-eight patients (18%) died during the sentinel hospitalization (13% died in the ICU). A total of 61 patients (28.9%) died during a median follow-up period of 15 months (interquartile range, 5-26 months). The echocardiographic variables associated with long-term mortality (from PE diagnosis) were ratio of RV to left ventricular end-diastolic diameter (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.2-4.8), tricuspid annular plane systolic excursion (HR, 0.53; 95% CI, 0.31-0.92), and RV-right atrial gradient (HR, 1.02; 95% CI, 1.01-1.4). ICU mortality was associated with ratio of RV to LV end-diastolic diameter (HR, 4.4; 95% CI, 1.3-15), RV systolic pressure (HR, 1.03; 95% CI, 1.01-1.05), tricuspid annular plane systolic excursion (HR, 0.4; 95% CI, 0.18-0.9), and inferior vena cava collapsibility < 50% (HR, 4.3; 95% CI, 1.7-11). These variables remain significantly associated with mortality after adjusting by Acute Physiology and Chronic Health Evaluation IV score, Pulmonary Embolism Severity Index score, or the use of thrombolytic agents. RV strain parameters were not correlated with hospital or long-term mortality.nnnCONCLUSIONSnFour simple parameters that measure different aspects of the right ventricle (ratio of RV to left ventricular end-diastolic diameter, RV systolic pressure, tricuspid annular plane systolic excursion, and inferior vena cava collapsibility) were independently associated with mortality in patients presenting with acute PE who were admitted to the ICU.

Special FeaturesBlack Bronchoscopy

A presence of black pigmentation involving the endobronchial tree is not uncommon. It was first described in the literature in association with occupational exposure in the early 1940s. However, in 2003, Packham and Yeow formally used the term black bronchoscopy to describe endobronchial metastasis from a malignant melanoma. Hyperpigmentation of the airway, however, is associated with multiple etiologies such as congenital disease, inborn errors of metabolism, infections, environmental exposures, neoplasm, and iatrogenic causes. Although the majority of these conditions are benign, a proper diagnosis is important for optimal management. In this article, we review the etiology of black bronchoscopy and discuss its presentations and current management guidelines.

Probability of developing proximal deep-vein thrombosis and/or pulmonary embolism after distal deep-vein thrombosis

Isolated distal deep-vein thrombosis (DDVT) of the lower extremities can be associated with subsequent proximal deep-vein thrombosis (PDVT) and/or acute pulmonary embolism (PE). We aimed to develop a model predicting the probability of developing PDVT and/or PE within three months after an isolated episode of DDVT. We conducted a retrospective cohort study of patients with symptomatic DDVT confirmed by lower extremity vein ultrasounds between 2001-2012 in the Cleveland Clinic Health System. We reviewed all the ultrasounds, chest ventilation/perfusion and computed tomography scans ordered within three months after the initial DDVT to determine the incidence of PDVT and/or PE. A multiple logistic regression model was built to predict the rate of developing these complications. The final model included 450 patients with isolated DDVT. Within three months, 30 (7u2009%) patients developed an episode of PDVT and/or PE. Only two factors predicted subsequent thromboembolic complications: inpatient status (OR, 6.38; 95u2009% CI, 2.17 to 18.78) and age (OR, 1.02 per year; 95u2009% CI, 0.99 to 1.05). The final model had a bootstrap bias-corrected c-statistic of 0.72 with a 95u2009% CI (0.64 to 0.79). Outpatients were at low risk (<u20094u2009%) of developing PDVT/PE. Inpatients aged ≥u200960 years were at high risk (>u200910u2009%). Inpatients aged <u200960 were at intermediate risk. We created a simple model that can be used to risk stratify patients with isolated DDVT based on inpatient status and age. The model might be used to choose between anticoagulation and monitoring with serial ultrasounds.

Pills and the air passages: a continuum

Recently, we reported a number of key, common medications that affect the air passages in a variety of fashions. The purpose of this article is to provide a comprehensive review of the literature on the subject, including supportive articles published in languages other than English. The presented information was gathered by a review of the English literature, by cross referencing, and by communication with other interventional pulmonologists. We identified several additional medications causing either direct or systemic effects on the air passages. In this review, we update the clinical presentation, mechanism of injury, diagnosis, and management of the airway complications related to these medications.

Comorbidities in Patients With Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation Outcomes

Purpose: The objective of this study was to evaluate the impact of comorbidities as potential predictors of the response to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). Methods: The study included 165 patients with COPD with exercise limitations. Comorbidity was classified as cardiac, metabolic, orthopedic, behavioral health problems, or other diseases. Number of comorbidities was grouped as 0, 1, or ≥2. Outcomes were defined as improvement in exercise capacity (maximal exercise capacity, 6-minute walk test, and constant workload cycle exercise duration) and quality of life (Chronic Respiratory Questionnaire). We assessed the effect of comorbidities on improvement in outcomes and the impact of the number of comorbidities on the percentage of patients reaching the minimal clinically important difference for each outcome. Results: Most patients (n = 160; 96%) were elderly males (mean age 70 years) with COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages II to IV. Sixty-four percent of patients had at least 1 comorbidity. The ≥2 comorbidity group (n = 29) had a higher modified Charlson index and more patients required continuous supplemental oxygen. Absolute differences in dyspnea scores in patients with cardiac disease and orthopedic problems compared with those without these comorbidities were 2.6 ± 0.87; 95% CI 0.89 to 4.32; p = .003, and −3.25 ± 1.23; 95% CI −5.69 to −0.82; p = .009, respectively. Comorbidities had no significant effect on other exercise outcomes or quality of life. Conclusion: Patients with cardiac disease experienced greater improvement in the dyspnea score compared with patients with no cardiac disease, whereas patients with orthopedic problems had a smaller but also clinically significant improvement in dyspnea after pulmonary rehabilitation.

Saber-sheath trachea in a patient with severe COPD

An 86-year-old man was evaluated for chronic cough and right lower lobe (RLL) mass. His medical history was significant for severe chronic obstructive lung disease (COPD). He had smoked one pack of cigarettes daily for 55u2005years. He had a barrel-shaped chest and diminished breath sounds in bilateral lungs were heard. CT of the chest noted RLL mass and abnormal configuration of the trachea (figure 1). Bronchoscopic examination showed an enlarged non-collapsible horseshoe-shaped trachea (figure 2). Endobronchial ultrasound with fine-needle aspiration of the left paratracheal lymph nodes revealed squamous cell carcinoma. A diagnosis of stage IIIb lung cancer was …

Severe case of asbestos-related lung diseases.

A 90-year-old man was referred for evaluation of shortness of breath. He had a significant history of asbestos exposure, dating back to when he removed asbestos insulation from a US Navy ship 60u2005years earlier. He had quit smoking 30u2005years prior to presentation. Physical examination was significant for inspiratory crackles. Pulmonary function test revealed moderate restrictive lung disease and severe reduction of diffusing capacity for carbon monoxide, consistent with clinical suspicion of asbestos-related lung disease. We show images of pleural and pulmonary asbestosis, …

PET artefact masquerading as a PET positive lung mass

A 70-year-old man was referred for evaluation of multiple lung nodules. His medical history was significant for stage IV non-Hodgkins lymphoma in remission for the past 10u2005years. Physical examination and laboratory tests were unremarkable. Positron emission tomography and CT (PET-CT) of the chest demonstrated non-hypermetabolic scattered pulmonary nodules measuring up to 1.0u2005cm in diameter and an intense fluorodeoxyglucose (FDG)-avid hypermetabolic lesion adjacent to the right hilum extending to the medial segment of the right lower lung (RLL), without any corresponding abnormality on …

Where Is the Convex-Probe Endobronchial Ultrasound Balloon? A Lessen to Learn

To the Editor: Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a minimally invasive bronchoscopic procedure with overall complication rate <1.5%.1 The complications of EBUS-TBNA such as needle fracture and retention within the lymph nodes,2 pneumothorax, airway bleeding requiring intervention, mediastinitis, and hypoxic respiratory failure have been reported in the literature.1 We describe a case of dislodged convex-probe EBUS balloon in the bronchus. Its pathophysiologic mechanism, and preventive measures are also discussed. If such a complication is unrecognized, it could lead to life-threatening consequences. A 71-year-old woman underwent right upper lobectomy for stage IB squamous cell lung carcinoma followed by 4 cycles of chemotherapy. Surveillance computed tomography of the chest 6 months later demonstrated an enlarged right paratracheal lymph node (station 4R) measuring 18 13mm in size. EBUS-TBNA was performed to determine tumor recurrence in the mediastinum. She underwent general anesthesia with endotracheal tube placement because of difficulty placing the laryngeal mask airway. A flexible bronchoscopy was initially advanced through the endotracheal tube to determine the airway anatomy and no endobronchial lesion was found. The tip of the endotracheal tube was just 1 cm above the carina and was withdrawn a couple of centimeters to allow access to the right paratracheal node. The EBUS balloon had to be inflated to establish a firm contact with the airway mucosa overlying the right paratracheal lymph node for obtaining adequate ultrasonic visualization of the node. Multiple TBNA were obtained while the endotracheal tube remained slightly above the tip of the EBUS bronchoscope. Rapid on-site evaluation of the specimens demonstrated the presence of squamous cell carcinoma confirming the diagnosis of tumor recurrence. The EBUS scope was advanced to the left hilar area for lymph node evaluation; however, the balloon inflation was not successful because the small crescent of the balloon usually seen on the fiber-optic image was not identified. The EBUS scope was withdrawn to evaluate the balloon, which was not found at the tip of the scope. Airway inspection using the flexible bronchoscope showed a foreign body at the orifice of the right lower lobe bronchus (Fig. 1). It was identified to be the dislodged balloon of the EBUS scope and was successfully retrieved using suction. Our explanation of this occurrence is that the balloon attached to the probe was rubbing against the endotracheal tube during right paratracheal node aspirations forcing the balloon to slip from the probe to the right lower lobe bronchus. If the EBUS scope is removed without attempting to inflate the balloon to visualize the left hilar nodes, the balloon could be left in the airways, which could have led to complications such as atelectasis and postobstructive pneumonia. It is important to confirm the presence of the balloon at the end of the EBUS procedure and to recognize that balloon migration to the airways can lead to potential complications if it goes unnoticed. Laryngeal mask

Tracheobronchial Airway Necrosis: An Atypical Presentation of Recurrent Osteosarcoma.

Received for publication March 6, 2016; accepted July 26, 2016. From the *Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University at Buffalo; and wRoswell Park Cancer Institute, Buffalo, NY. P.T., K.H., J.B., and A.H.A. prepared the manuscript or revised it critically for important intellectual content. Disclosure: There is no conflict of interest or other disclosures. Reprints: Pichapong Tunsupon, MD, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University at Buffalo, Western New York Veterans Administration Healthcare System, 3495 Bailey Avenue, Buffalo, NY 14215 (e-mail: ptunsupon@gmail.com). Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/LBR.0000000000000327 IMAGES IN INTERVENTIONAL PULMONOLOGY